540 Underpass Rd Davie County,NC Tax Parcel Report Friday,November 18, 2016
WARNING: THIS IS NOT A SURVEY
Parcel Information
Parcel Number: `.F90000003501 Township: Shady Grove
NCPIN Number: 5880552327 Municipality:
Account Number: . : 58216000 Census Tract: 37059-804
Listed Owner 1: POTTS TIMOTHY V'-' Voting Precinct: EAST SHADY GROVE
Mailing Address 1: 173 IN AND OUT LANE ! Planning Jurisdiction: Davie County
City: ADVANCE Zoning Class: DAVIE COUNTY R-A
State:- - NC Zoning Overlay:
Zip Coder 27006-7802 Voluntary Ag.District: No
Legal Description: 1.16 AC OFF UNDERPASS RD: Fire Response District: ADVANCE
Assessed Acreage: 1.16 Elementary School Zone: SHADY GROVE
Deed Date: 5/1978 Middle School Zone: WILLIAM ELLIS
Deed Book/Page: 001040676 Soil Types: PaD,PcC2
Plat Book: Flood Zone:
Plat Page: Watershed Overlay: DAVIE COUNTY
Building Value: 0.00 Outbuilding&Extra 0.00
Freatures Value:
Land Value: 15640.00 Total Market Value: 15640.00
Total Assessed Value: 15640.00
All data Is provided as Is without warranty or guarantee of any kind either expressed or Implied Including but not limited to the
Davie County, Implied warranties of merchantability or fitness for a particular use.All users of Davie County's GIS website shall hold harmless the
County of Davie,North Carolina,Its agents,consultants,contractors or employees from any and all claims or causes of action due to
no6N� NC or arising out of the use or inability to use the GIS data provided by this website.
- ('OPERATION PERMIT or ice se n v
*± Davie County Health Department *CDP File Number 202171 -1
wy 4 rpt` _
210 Hospital Street
County ID Number.
P.O. Box 848
Mocksville - NC 27028 Evaluated For. NEW
Phone:336-753-6780 Fax:336-753-1680 Township:
Applicant: Timothy Potts Sr. Property Owner: Timothy Potts Sr.
_Address: 173 In and Out Lane_ Address: 173 In and Out Lane -
City: Advance City: Advance
State/ZIP: NC 27006 State/Zip: NC 27006
Phone#: (336)971-5134 'Phone#: (336)971-5134
Property Location & Site Information
AddresslRoad #: Subdivision: Phase: Lot:
Underpass Road
:. _Advance NC 27006 Directions
Underpass Road east of#536
Structure ' SINGLE FAMILY -
#of Bedrooms: 1
#of People:
*Water Supply: PUBLIC
*IP issued by 2140 Nations Robert *System Classification/Description:
_. i TYPE III G.OTHER NON-CONN.TRENCH SYSTEMS
-CA issued by: 2140-Nations,Robert Saprolite System? QYes QNo
Design Flow: _--a ..4 0 GRAVITY-SERIAL Pump Required?
- - - Distribution Type:
QYes QNo
Soil Application Rate: 0 3 'Pre-Treatment:
Drain field
rNo.
cation Field
$ 0 _ 0 Sq.ft. `System Type: INFILTRATOR QUICK 4 STANDARD .
rain Lines 3 Installer: Martin Cater
ToaTrench Length: a 0 0 ft. Certification#: 3027
Trench Spacing: _ 9 Inches O.C.
gFeet O.C. *EHS: 2140-Nations,Robert
Trench Width: r 3OInches
QFeet Date: 1 1 / 0 1 / .2 0 1 6
Aggregate Depth: inches
Minimum Trench Depth: 3 6
Inches
Minimum Soil Cover. a 4 Approval Status
Inches
Maximum Trench Depth: 3 6 ®"Approved O Disapproved.
inches
Maximum Soi[Cover: a 4 inches
CDP File Number 202171 - 1 County ID Number:
Septic Tank _
Manufacturer. Shoaf Lat.
STB: 760
Long: ,
Gallons:
1000 Installer: Martin Cater
- Certification#: 3017
Date: 0 8 / 1 5 / .2 0 1 6 _
*EH S: 2140-Nations.Robert
`Filter Brand: POLYLOK Dual PL-122 With Pipe Adapter
ST Marker: El Yes E No
Date: 1 1 / 0 1 / 2 0 1 6
Reinforced Tank: ❑ Yes El No Approval'Status
Piece Tank�- Approved ETDisapproved
Pump Tank
Manufacturer Installer.
PT: Certification#:
i
Gallons: *EH S:
Date: / / Date:
RiserSealed ❑ Yes ❑ No
RiserHeight: ❑ Yes ❑ No '(Min. in.) Approvalstetus
Reinforced Tank: ElYes -❑ . No
--D'Approved Dfsap ironed,
KlPiepce Tank:_❑ Yes ❑ No_
_-.-- _ Supply Line
Pipe Size: inch diameter Installer,
Pipe Length: feet Certification#:
*EHS:
*Schedule:
Pressure Rated [] Yes - _ . ❑ NO Date: ,
Approved fittings ❑ Yes ❑ NO Approvat Status
❑ Approved❑ Disapproved
u p Requirement
Pump Type: Installer:
Dosing Volume: — Gal Certification#:
Draw Down: Inches THS:
*Chad:
Date:
Valves Accessible ❑ Yes ❑ No
Flow Adjustment Valve ❑ Yes ❑ No
Check-valve ❑ Yes ❑ No Approval Status;`
PVC unions E] Yes El No ❑ Approved El Disapproved
Vent Hole ❑ Yes ❑ No
Anti-siphon Hole ❑ Yes ❑ No
CDP File Number 202171 : 1 County ID Number:
Electric Equipment
NEMA 4X Box or Equivalent El Yes ❑ No Installer.
Box.12 inches Above Grade El Yes ElNo
Certification#:
Box Adj.To Pump Tank ❑ Yes ❑ No
Conduit Sealed ❑ Yes ❑ No 1EHS:
Pump Manually Operable ❑ Yes ❑ No 1 1
"Activation Method: Date:
Alarm Audible ❑ Yes ElNo Approval Status
Approved❑ Disapproved=
Alarm ble
1:1 Yes ❑ NO
2140-Nation.Robert
*Operation Permit completed by:
1
Authorized State Ag t: Date of Issue: 1 1 / 0 1 / 2 0 1 6
-,Owner/Applicant Signature:
This system has been installed in compliance with.applicable NC General Statutes:Article 11, Chapter 130A, Rules for
Sewage Treatment and Disposal, 15A NCAC .18A.1900 et. Seq.,and all conditions of the Improvement Permit and
Construction Authorization.-This property,is served by a TYPE III G. sewage septic system.
Rule�A961 requires'that a Type -.TYPE III G. septic system meet the following criteria:
Minimum.System Review By The Local Health Department: NIA
.__ Management Entity: OWNER
Minimum System Inspection/Maintenance FrequencyByCertified Operator:
NIA
Reporting Frequency By Certified Operator: NIA
Rule.1961 requires that a Type IV and V septic systems designed fora home/business owner must maintain a valid contract
with a public management entity with a certified operator ora private certified operator for the life of the septic system.
Rule.1961 requires that Type VI septic systems designed for a home/business owner must maintain a valid contract with a
public management entity with a certified operator for the life of the septic system.
Rule. 1961 (2)(e)requires a contract shall be executed between the system owner and a management entity prior to the
issuance of an Operation Permit for a system required to be maintained bya public or private management entity,unless the
system ownerand certified operator are the same. The contract shall require specific requirements formaintenance and
operation, responsibiities of the owner and systems operator,provisions that the contract shall be in effect for as long as the
system is in use, and other requirements for the continued proper performance of the system. It shall also be a condition of
the Operation Permit that subsequent owners of the systems execute such a contract.
@Hand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
OPERATION PERMIT 202171 9
Davie County Health Department CDP File Number: r -
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date:
Q Inch -
Drawing Drawing Type:-Operation Permit Scale: . ON A k
I '
I V I I I I
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CONSTRUCTION For Office'Use Only
AUTHORIZATION *CDP File Number 202171-1
a Davie County Health Department County ID Number.
210 Hospital Street Evaluated For NEW
P.O. Box 848 Township:
Mocksville NC 27028 PERMIT VALID UNTIL:
Phone: 336-753-6780 Fax:336-753-1680 0 9 / a 6 a 0 a 1
Applicant: Timothy Potts Sr. Property Owner: Timothy Potts Sr.
Address: 173 In and Out Lane Address: 173 In and Out Lane
City: Advance City: Advance
State/Zip: NC 27006 State/Zip: NC 27006
Phone#: (336)971-5134 Phone#: (336)971-5134
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Underpass Road
Advance NC 27006 Directions
Structure:` SINGLE FAMILY Underpass Road east of#536
#of Bedrooms: 1
#of People:
*Water Supply: PUBLIC
System Specifications
Minimum Trench Depth: a 4
Site Classification: Provisionally Suitable Inches
Minimum Soil Cover. 1 a Inches
Saprolite System? QYes QNo
Design Flow: a 0 Maximum Trench Depth: Inches
Soil Application Rate: 0 3 Maximum Soil Cover: a 4 Inches
*System Classification/Description: *Distribution Type: GRAVITY-SERIAL
TYPE II A.CONV SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Septic Tank: 1
Gallons
*Proposed System: 25%REDUCTION 1-Piece: QYes QNo
Pump Required: QYes QNo @May Be Required
Nitrification Field 8 0 0
Sq. ft. Pump Tank: 1 0 0 , 0 Gallons
No. Drain Lines 3 1-Piece: OYes QNo
Total Trench Length: a 0 0 GPM—vs— ft. TDH
Trench Spacing: 9 (Inches O.C. Dosing Volume: Gallons
Feet O.C. ,
Trench Width: Q Inches
3 Feet Grease Trap: Gallons
Aggregate Depth: inches
Pre Treatment: ONSF OTS-1 OTS-11
Septic Tank Installer Grade Level Required: 01011 O 111 01V
Donn 1 of Z
CDP File Number 202171 - 1 County ID Number
❑ Open Pump System Sheet
Repair System Required:@Yes ONO ONO, but has Available Space
rDesign
System Trench Spacing: Inches 0.0
ification: Provisionally Suitable 9 ( Feet O.C.
Trench Width: Inches
w: a 4 _ , 3 Feet
et
Depth:
Appl�ation Rate: 0 3 inches
a
*System Classification/Description: Minimum Trench Depth: 4 Inches
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR LESS) Minimum Soil Cover. a Inches
Maximum Trench Depth: 3 6 Inches
*Proposed System:. 25°fo REDUCTION
- Maximum Soil Cover. 2 4
Nitrification Field Inches
8 0 0 Sq.ft.
N o. Drain Lines *Distribution Type: GRAVITY-SERIAL
3
Total Trench Length: 2 0 0 ft - Pump Required: QYes ONo @May Be Required
'Pre Treatment: ONSF OTS-I OTS-II
*Site Modifications
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
i
*Permit Conditions
The issuance of this permit bythe Health Department in no wayguarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements. ;
This Authorization for Wastewater System Construction shall be valid fora person equal to the period of validity of the Improvement Permit,not
to exceed five years,and may be Issued atthe same time the Improvement Permit issued(NCGS 130A-336(b)}If the installation has not been
completed during the period of validity of the Construction Penni;the Information submitted in the application for a permit or Construction
Authorization Is found to have been Incorrect,falsified or changed,or the site is altered,the permit or Construction Authorization shall become
invalid,and may be suspender!or revolted(.1937(g)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,Installation,operation,maintenance,monitoring,reporting and repair
(1938(b)).
Applicariftegal Reps. Signature Required? Oyes ONO
Applicant/Legal Reps.Signature: Date:
*Issued By: 214t)-Nations,Robert Date of Issue: . 0 9 / a 6 / a 0 1 6
Authorized State Agent: Malfunction Log OYes
21
QHand Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
CONSTRUCTION AUTHORIZATION 2Q2171 - 1
Davie County Health Department CDP File Number:
210 Hospital Street
P.O.Box 848 County File Number:
Mocksville NC 27028 Date: 0 9 / 26 / ;20 1 6
�4
Q Inch
DraON/A
wing Drawing Type: Construction Authorization Scale: , ft.
QN1
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CONSTRUCTION AUTHORIZATION ,
Davie County Health Department
210 Hospital Street CDP File Number: 202171 - 1
P.O.Box 848
Mocksville NC 27028 County File Number:
G
Date: .0 .0_/ 26 / 2 0 1 6
Click below to Import an image from an external location: Drawing Type:Construction Authorization
v � _
� IMPROVEMENT PERMIT For officelJseOnly
*CDP Fite Number 202171 -1
0 Davie County Health Department
210 Hospital Street County ID Number.
P.O. Box 848
Evaluated For. NEW
Mocksville NC 27028 Township;
Phone: 336-753-6780 Fax:336-753-1680 PERMIT VALID UNTIL: 4/21/2021
*NOTE TO INSPECTIONS DIVISION: Building Permits cannot be Issued with this Improvement Permit.
Applicant: Timothy Potts Sr. PropertyOwner. Timothy Potts Sr.
Address: 173 In and Out Lane Address: 173 In and Out Lane
City: Advance City: Advance
State2ip: NC 27006 StatefZip: NC 27006
Phone#: (336)971-5134 phone#: (336)971-5134
Property Location & Site Information
Address/Road#: Subdivision: Phase: Lot:
Underpass Road
Advance NC 27006 Directions
Structure: SINGLE FAMILY Underpass Road east of#536
#of Bedrooms: 1
#of People:
*Water Supply: PUBLIC
System Specifications
nitial System.
Site GlassI scat ton: Provisionally Suitable
Minimum Trench Depth: 2 4 Inches
Sap rolite System? QYes ®No Maximum Trench Depth: 3 6
Inches
Design Flow: a 4 0 Septic Tank: 1 0 0 0
Gallons
Soil Application Rate: 0 3
1-Piece: QYes QNo
i
*System Class ificatbn/Description: Pump Required: QYes QNo OMay Be Required
TYPE II A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR Pump Tank: Gallons
LESS)
*Proposed System: 25%REDUCTION 1-Piece: Q Yes Q No
Repair System Required:@Yes ONO ONo, but has Available Space
Repair System
*Site Classification: Provisionally Suitable Minimum Trench Depth: a 4
Inches
Soil Application Rate: 0 3 Maximum Trench Depth: 3 6 Inches
u
*System Classification/Description: Pump Required: QYes Q No Q Maybe Required
TYPE 11 A.CONY SYSTEM(SINGLE-FAMILY OR 480 GPD OR
LESS)
*Proposed System: 25%REDUCTION
Pagel of 3
CDP File Number 202171 - 1 County ID Number: 1,
"Site Modifications ❑ Open Fill Sheet
No grading or construction activity is allowed in areas designated for system and repair without approval of Health Department.
"Permit Conditions
The issuance of this permit by the Health Department in no way guarantees the issuance of other permits.The permit holder
is responsible for checking with appropriate governing bodies in meeting their requirements.
Site Plan The Improvement Permit shall be valid for 6 years from date of issue with a site plan(means a drawing not necessarily drawn to
scale that stows the existing and proposed property lines with dimensions,the location of the facility and appurtenances,the
O
e site for the proposed Wastewater system,and the location of water supplies and surface waters).
Plat The Improvement Permit shall be valid without expiration with plat(means a property surveyed prepared by a registered land
O surveyor,drawn to a scale of one inch equals no morethan 60 feet,that Includes:the specific location of the proposed facility
and appurtenances,the site for the proposed Wastewater system,and the location of water supplies and surface waters. Plat
also means,for subdivision lots approved by the local planning authority and recorders with the county register of deeds,a copy
of the recorded subdivisions plat that is accompanied by a site plan that is drawn to scale).
The Department and local Health Department may Impose conditions on the Issuance and may revoke the permits for failure of
the system to satisfy the conditions,the rules,or this article.This permit Is subject to revocation if the site plan,plat,or Intended
use changes(NCGS 130A-336(l)).The person owning or controlling the system shall be responsible for assuring compliance
with the laws,rules,and permit conditions regarding system location,installation,operation,maintenance,monitoring,
reporting,and repair(.1938(b)}
Applicant/Legal Reps.Signature Required? Oyes ONO
Applicant/Legal Reps. Signature; Date:
"Issued By: 2140-NaUons,Robert Date of Issue: 0 4 / a 1 / a 0 1 6
Authorized State Agent: OValid without Expiration?
OCreate CA.
01-land Drawing Olmport Drawing
**Site Plan/Drawing attached.**
Page 2 of 3
IMPROVEMENT PERMIT 202171 - 1
•' Davie County Health Department CDP File Number:
210 Hospital Street
P.O.sox 848 County File Number:
Mocksville NC 27028 Date:
Qinch
Drawing Drawing Type: Improvement Permit Scale: • QBlock
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IMPROVEMENT PERMIT '
Davie County Health Department ,
210 Hospital Street CDP File Number: 202171 - 1
P.O.Box 848
Mocksville NC 27028 County File Number:
Date: 04 / 1 / 2016
Click below to import an image from an external location:Drawing Type: Improvement Permit
TION FOR SITE EVALUATION/IMPROVEMENT PERMIT&ATC
Davie County Environmental Health
pate P.O,sox 88/210 Hospital Street
:Alocksvillc,NC 27028
(336)733-6780/Fax(336)753-1680
Application For. D Site Evaluation/Improvement Permit C Authorization To Construct(ATC) 6/Both
Type of Application: ❑New System ❑Repair to Existing System DExpansion/Modificatioa of Existing System or Facility
***IMPORTANT***THIS APPLICATION CANNOT BE PROCESSED UNLESS ALL OF THE REQUIRED
INFORMATION IS PROVIDED. Refer to the INFORMATION BULLETIN for instructions.
APPLICANT INFORMATIO1N 0�� (T'J a 7
Name �1,k)-t' �4 W �91 S S Contact Person C S
Address Ili-,) :!;,�R o-,& 0w+ L-v.,— Home Phone 2 t Y
City/State/ZIP ckJ c, 0 0 Business Phon 3 3 -1 -3
Email-e a e1n wti r -o P e reo Ca--Email: 6 s
Name on Permit/ATC if Different than AN
Mailing Address 013 --5 Y�, cs,ti Q v` City/State/Zip tt C-
// p Q S
PROPERTY INFORMATION *Date House/FacilityCorners Fla ed 6-a g'/ 0
NOTE: A survey plat or site plan must accompany this application. Included:U Site Plan UPlat(to scale)
(Permit is valid for 6 on�hs with site plan,no expiration with complete plat.)
Owner's Name-- i V� c't'C S ry PhponcNumber�S-_
Owner's Address li Ci /S ate/Zi (,I+ !] _G e `02d o G
Property Address--U to e-r ea-8 S YDad City .J 4,
Lot Size Tax PIN#
Subdivision Name(if applicable) Sectiot,/�ot#
Directions To Site:/Crc— @ 11 vX 4Y�8 b' 11 rr
If the answer to any of the following questions is"Yes",supporting documentation must be attached:
Are there any existing wastewater systems on the site? Yes -No
Does the site contain jurisdictional wetlands? Yes!No
Are there any easements or tight-of-ways on the site? Yes eNo
Is the site subject to approval by another public agency? Yes ,'No
Will wastewater other than domestic sewage be generated? Yes 7No
IF RESIDENCE FILL OUT THE BOX BELOW
#People 2 #Bedrooms ( #Bathrooms I � Garden Tub/Whirlpool I Wes N
Basement. es o Basement Plumbing: :)Yes 2No
IF NON-RESIDENCE FILL OUT THE BOX BELOW
Type of FacitityBusiness Total Square Footage ofBuilding #People
#Sims #Commodes tt�Dowers #Urinals
Estimated Water Usage(gallons per day) (Attach documentation of similar facilitywater consumption)
FOODSERVICE ONLY:: #Seats
Type system requested: 6Conventional ❑Accepted ❑Innovative ❑Alternative ❑Other
Water Supply Type:County/City Water ❑New Well Misting-Well 7 Community Well
Do you anticipate addition or expaasi ns of a facility this system is intended to serve?[?Ifes 0 No
If yes,what type? ��0
This is to certify that the information provided on this application is true and correct to the best of my knowledge. I understand that
any permit(s)or ATC(s)issued hereafter are subject to suspension or revocation if the site is altered,the intended use changes,or if
the information submitted in this application is falsified or changed. I hereby grant right of entry to the Authorized Representative
of the Davie County Health Departrme"Wduct necessary inspections to determine compliance with applicable laws and rules.
I understand that I am responsible for the proper identification and labeling of property lines and corners and locating and flagging
or staging the h� acility location,proposed well location and the location of any other amenities.
Property owner's or owner's legal representative signature She Revisit Charge
DSS)'No--.�-,��
Client tif�lon Date:
Date ERS:
Sign given I Yes❑No Account# c2 0 R /7/
Revised 11/06 Invoice#
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DAVIE COUNTY HEALTH DEPARTMENT
• Environmental Health Section
Soil/Site Evaluation
APPLICANT INFORMATION PROPERTY INFORMATION
PeV P���s
Water Supply: On-Site Well Community Public el-
Evaluation By: Auger Boring Pit Cut
FACTORS 1 2 3 4 5. 6 7
Landscape position i.
Slope% L� 2
HORIZON I DEPTH --}7
Texture group
Consistence r
Structure 5 tG IC
Mineralogy
HORIZON H DEPTH
Texture group 'tc G L
Consistence L tr
Structure" C
Mineralogy
HORIZON III DEPTH s'
Texture group
Consistence
Structure
Mineralogy
HORIZON IV DEPTH
Texture group
Consistence
Structure
Mineralogy
SOIL WETNESS
RESTRICTIVE.HORIZON
SAPROLITE
CLASSIFICATION
LONG-TERM ACCEPTANCE RATE a2 4 , 27
SITE CLASSIFICATION: EVALUATION BY: Cl 4
LONG-TERMACCEPTANCERATE: r OTHER(S)PRESENT-
REMARKS:
LEGEND
Landscape Position
R-Ridge S -Shoulder L-Linear slope FS-Foot slope N-Nose slope
CC-Concave slope CV-Convex slope T-Terrace FP-Flood plain H-Head slope
Texture
S -Sand LS-Loamy sand SL-,Sandy loam L-Loam SL-Silt
SICL-Silty clay loam SIL-Silty loam CL-Clay loam SCL-Sandy clay loam
SC-Sandy clay SIC-Silty clay C-Clay
CONSISTENCE
Moist
VFR-Very friable FR-Friable FI-Firm, VFI-Very firm EFI-Extremely firm
NS-Non sticky SS-Slightly sticky S-Sticky VS-Very Sticky
NP-Non plastic SP-Slightly plastic P-Plastic VP-Very,plastic
SStructure
SC-Single grain M Massive CR-Crumb GR-Granular ABK-Angular blocky
SBK-Subangular blocky PL-Platy PR-Prismatic
Mineralogy
1:1,2:1,Mixed
Nato
Horizon depth-.In inches
Depth of fill-In inches
Restrictive horizon-Thickness and inches from land surface
Saprolite-S(suitable),U(unsuitable)
Soil wetness-Inches from land surface to free water or inches from land surface to soil colors with chroma 2 or less
Classification-S(suitable),PS(provisionally suitable),U(unsuitable)
LTAR-Long-term acceptance rate-sal/dav/ft2 nmm nvnc ine.,..ea%